MEDICARE: BAY RADIOLOGY WOMENS IMAGING CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	V2983	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1558537514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAY RADIOLOGY WOMENS IMAGING CENTER LLC

Provider Business Mailing Address
First Line	:	PO BOX 1770
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32402-1770
Country	:	US
Telephone Number	:	850-747-4905
Fax Number	:	850-747-4907

Provider Business Practice Location Address
First Line	:	330 W. 23RD ST.
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-7614
Country	:	US
Telephone Number	:	850-763-2451
Fax Number	:	850-747-4908

Authorized Official
Title or Position	:	CEO
Name	:	DR. LLOYD G. LOGUE
Credential	:	D.O.
Telephone Number	:	850-763-2451

Provider Enumeration Date	:	04/30/2008
Last Update Date	:	12/31/2009

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